Basic Information
| Provider Information | |||||||||
| NPI: | 1447330741 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | MITCHELL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 520 ROSE LN | ||||||||
| Address2: | |||||||||
| City: | WICKENBURG | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853901447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286844365 | ||||||||
| FaxNumber: | 9286842434 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 ROSE LN | ||||||||
| Address2: | |||||||||
| City: | WICKENBURG | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853901447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286844365 | ||||||||
| FaxNumber: | 9286842434 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 02/03/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 27272 | AZ | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XX0801X | 27272 | AZ | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma |
ID Information
| ID | Type | State | Issuer | Description | 457920 | 05 | AZ | MEDICAID | AZ0866130 | 01 | AZ | BCBS | OTHER | 7878067 | 01 | AZ | AETNA | OTHER |